Improving access and quality of primary healthcare through women and adolescents' user committees: A mixed-methods case study in Kinshasa, Democratic Republic of the Congo

BACKGROUND

Patient engagement is seen as a fundamental strategy for achieving quality patient-centred care, especially in community-based primary healthcare. Despite growing interest in patient engagement in Sub-Saharan Africa, few patient engagement initiatives have been identified, and those often are limited to lower levels of engagement, in participation in health research or in health system improvement. With the aim of giving a voice to under-represented community groups in healthcare governance, the Access to Health services in Kinshasa (ASSK) project supported the implementation of primary health services user committees in the Democratic Republic of the Congo, designed to enable the representation of two user groups with specific unmet sexual and reproductive health (SRH) needs: women and adolescents.

AIMS AND METHODS

Using a mixed-method case study design combining quantitative secondary data (from the national health management information system-DHIS2) and qualitative data from two research World Café (WC1: Women user committees (WUC) n = 55; WC2: Adolescents user committee (AUC) n = 63), this paper looks at the implementation facilitators and barriers, and at the results of this initiative.

RESULTS

Women and adolescent members of the user committees highlighted that their participation resulted in increased knowledge of SRH and their related rights, as well as in their 'soft skills' such as communication and leadership. In addition, participants reported greater transparency and accountability on the part of the community primary health centres (e.g. by displaying fees for procedures to counter over-billing). Ultimately, WUC and AUC were associated with improved health practices in the community such as increased use of SRH services (increase of 613% for Makala and 160% for Maluku II), including adolescent family planning (increase of 320% for Makala and 12% for Maluku II) and assisted childbirth for women15-49 years old (increase of 283% for Makala and 23% for Maluku II)).

CONCLUSIONS

Patient user committees for specific marginalised or under-represented groups appear to be an effective way of improving the quality of primary health care services. Further research is needed to better understand how to maximise its potential.

Is this really Empowerment? Enhancing our understanding of empowerment in patient and public involvement within clinical research

BACKGROUND

There has been a growing push to involve patients in clinical research, shifting from conducting research on, about, or for them to conducting it with them. Two arguments advocate for this approach, known as Patient and Public Involvement (PPI): to improve research quality, appropriateness, relevance, and credibility by including patients' diverse perspectives, and to use PPI to empower patients and democratize research for more equity in research and healthcare. However, while empowerment is a core objective, it is often not clear what is meant by empowerment in the context of PPI in clinical research. This vacancy can lead to insecurities for both patients and researchers and a disconnect between the rhetoric of empowerment in PPI and the reality of its practice in clinical trials. Thus, clarifying the understanding of empowerment within PPI in clinical research is essential to ensure that involvement does not become tokenistic and depletes patients' capacity to advocate for their rights and needs.

METHODS

We explored the historical roots of empowerment, primarily emerging from mid-20th century social movements like feminism and civil rights and reflected the conceptual roots of empowerment from diverse fields to better understand the (potential) role of empowerment in PPI in clinical research including its possibilities and limitations.

RESULTS

Common themes of empowerment in PPI and other fields are participation, challenging power structures, valuing diverse perspectives, and promoting collaboration. On the other hand, themes such as contextual differences in the empowerment objectives, the relationship between empowerment and scientific demands, research expertise, and power asymmetries mark a clear distinction from empowerment in other fields.

CONCLUSION

PPI offers potential for patient empowerment in clinical trials, even when its primary goal may be research quality. Elements like participation, sharing opinions, and active engagement can contribute to patient empowerment. Nonetheless, some expectations tied to empowerment might not be met within the constraints of clinical research. To empower patients, stakeholders must be explicit about what empowerment means in their research, engage in transparent communication about its realistic scope, and continuously reflect on how empowerment can be fostered and sustained within the research process.

Challenges in engaging patients in feedback conversations for health care professionals' workplace learning

INTRODUCTION

Patient feedback is relevant information for improvement of health care professionals' performance. Engaging patients in feedback conversations can help to harness patient feedback as a powerful tool for learning. However, health care settings may prevent patients and health care professionals to effectively engage in a feedback dialogue. To advance our understanding of how feedback conversations may support learning in and from practice, we sought to explore patients' and health care providers' perspectives on engaging patients in feedback conversations as informal learning opportunities.

METHODS

For this qualitative study, we used a pragmatic approach and conducted semi-structured interviews with 12 health care providers and 10 patient consultants. We applied an inductive approach to thematic analysis to understand interviewees' perceptions regarding patient feedback for workplace learning.

RESULTS

Participants attributed importance to patient feedback and described how the feedback may improve treatment relationships, professionals' performance and care processes on the team level and the organisational level. Participants experienced conflicting roles as patient and educator or expert and learner, respectively. Changing relationships, feelings of vulnerability and perceived power dynamics in treatment relationships would affect participants' engagement in feedback conversations. Patients and professionals alike saw a role for themselves in giving or inviting feedback but often missed the tools for engaging in feedback conversations.

DISCUSSION

Patient feedback can contribute to professionals' practice-based learning but requires navigating tensions around conflicting roles and power dynamics in the treatment relationship. Both patients and health care professionals need to embrace vulnerability and may need facilitation and guidance to use patient feedback effectively. Attention to power dynamics, if not a shift towards collaborative relationships, is however crucial to engage patients in feedback conversations, thereby capitalising the power patients posses.

"We're back in control of the story and we're not letting anyone take that away from us": patient teacher programs as means for patient emancipation

While patient engagement in healthcare professions education (HPE) has significantly increased in the past decades, a theoretical gap remains. What are the varied reasons as to why patients get involved with HPE programs? With a focus on understanding what drives patient involvement with HPE programs, this study examined how a patient as teacher (PAT) program was experienced by medical students, patient teachers, and faculty within a medical school. Through a phenomenographic approach, this study captures and describes the different ways our study participants experienced a PAT program (the 'phenomenon'). 24 semi-structured interviews were conducted in total, comprised of interviews with patient teachers (N = 10), medical students (N = 10) and program facilitators (N = 4) who participated in a PAT program. Our focus was on participants' description of the program and was grounded in their experiences of as well as their beliefs about it. Our findings captured 4 layers representing the qualitatively different (yet interrelated) ways in which participants experienced/perceived and conceptualized the various aspects of their experience with the PAT program: (1) A productive disruption of the learning space (2) A re-humanization within healthcare (3) A means of empowerment and agency (4) A catalyst for change and emancipation. Our outcome space results can be visually illustrated by a nesting "Matryoshka" doll, representing the four layers and depicting the process of uncovering the less conscious layers of sense-making within this phenomenon. HPE programs that are co-produced with patients and actively involve patients as teachers have the potential, but not guarantee, to be emancipatory. To engage in PAT programs that exhibit an emancipatory potential, we need to consider transformative paradigms of education, which are aligned with social change, and disrupt the traditional teacher-learner hierarchy.

Patients' perspectives on their motivations for participating in non-clinical medical teaching and what they gain from their experience: a qualitative study informed by critical theory

In 2019-2021, we engaged in a project aimed at developing, implementing, and evaluating an educational intervention actively involving patient-teachers in undergraduate medical education at Université Laval, Quebec, Canada. Patient-teachers were invited to participate in small group discussion workshops during which medical students deliberate on legal, ethical, and moral issues arising from medical practice. Patients were expected to bring other perspectives, based on their experience with illness and the healthcare system. Little is still known about patients' perspectives on their participation experience in such context. Informed by critical theory, our qualitative study aims to document,: (i) the motivating factors for patients' participation in our intervention; and (ii) what patients gained from the experience. Data collection was based on 10 semi-structured interviews with patient-teachers. A thematic analysis was conducted using NVivo software. Motivators for participation arose from: (i) perceived consistency between patients' individual characteristics and those of the project, and (ii) conceiving the project as a means to reach individual and social goals. What patients gained mainly refers to (1) the appreciation of a positive, enriching, motivating yet uncomfortable and destabilizing experience; (2) a deconstruction of biases against the medical field and critical thinking about their own experience; (3) new knowledge, with a potential impact on their future interactions with the healthcare system. Results reveal patients as non-neutral thinking and knowing subjects, engaged in the participation experience as active teachers and learners. They also highlight the empowering and emancipatory nature of the learning gained through patients' participation experience. These conclusions prompt us to promote transformative interventional approaches that question the pervasive power issues in medical teaching and value patients' specific knowledge in teaching and learning the Art of Medicine.

A patienthood that transcends the patient: An analysis of patient research partners' narratives of involvement in a Canadian arthritis patient advisory board

OBJECTIVES

Incorporating the perspectives of patients and public into the conduct of research has the potential to make scientific research more democratic. This paper explores how being a patient partner on an arthritis patient advisory board shapes the patienthood of a person living with arthritis.

METHODS

An analysis was undertaken of the narratives of 22 patient research partners interviewed about their experiences on the Arthritis Patient Advisory Board (APAB), based in Vancouver, Canada.

RESULTS

Participants' motivations to become involved in APAB stemmed largely from their desire to change their relationship with their condition. APAB was a living collective project in which participants invested their hope, both for their own lives as patients and for others with the disease.

CONCLUSIONS

Our findings highlight how the journeys of patient partners connect and integrate seemingly disparate conceptions of what it means to be a patient. One's experience as a clinical 'patient' transforms into the broader notion of civic patienthood.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

Regulatory scripting: Stakeholder participation in food and drug administration medical device advisory meetings

In an age of biomedicalization, medical devices have become more common and more technologically complicated, and adverse events associated with medical devices have increased. The U.S. Food and Drug Administration (FDA) relies on advisory panels to assist in regulatory decision making regarding medical devices. Public meetings held by these advisory panels allow stakeholders to testify, presenting evidence and recommendations, according to careful procedural standards. This research examines the participation of six stakeholder groups (patients, advocates, physicians, researchers, industry representatives and FDA representatives) in FDA panel meetings focused on the safety of implantable medical devices between 2010-2020. We use qualitative and quantitative methods to analyze speakers' opportunities for participation, bases of evidence, and recommendations, applying the concept of 'scripting' to understand how this participation is shaped by regulatory structures. Regression analysis demonstrates statistically significant differences in speaking time, where researchers, industry, and FDA representatives had longer opening remarks and more exchanges with FDA panelists than patients. Patients, advocates and physicians shared the least amount of speaking time, and were the parties most likely to leverage patients' embodied knowledge and recommend the most stringent regulatory actions like recalls. Meanwhile, researchers, FDA, and industry representatives rely on scientific evidence and, with physicians, recommend actions that preserve medical technology access and clinical autonomy. This research highlights the scripted nature of public participation and the types of knowledge considered in medical device policymaking.

A scoping review of qualitative studies on parents' perspectives on speech, language, and communication interventions

PURPOSE

This scoping review synthesized existing qualitative studies to provide conceptual clarity to "parents' perspectives" in speech, language, and communication interventions for children.

METHODS

Peer-reviewed articles published between January 2009 and June 2019 were reviewed in accordance with the steps recommended by Arksey and O'Malley. In total, 1883 unique records were screened, and 40 studies met inclusion criteria. Inductive content analysis was used to analyze the research questions and major themes reported in studies.

RESULTS

The included studies were conducted across geographical regions and included parents of children of different ages and clinical diagnoses. Eight aspects of parents' perspectives were identified: access, decision making, implementation, relationship, roles, impact, expectations, and general experience. In addition, a subset of studies explored parents' opinions regarding technologies used in therapy.

CONCLUSIONS

Findings from this review suggest that parents' perspectives have been explored across a range of geographical locations on interventions for various clinical populations. The identified categories provide some conceptual clarity for clinicians and for future research on this topic. Future studies should (i) better adhere to qualitative study reporting standards; (ii) explore parents' perspectives regarding the context of speech language therapy; and (iii) include all parents' perspectives in speech and language interventions.IMPLICATIONS FOR REHABILITATIONParents' perspectives in communication interventions are complex and multifaceted.Clinicians and researchers can consider parents' perspectives using the eight, broad thematic categories identified in this scoping review.

Patients as experts in the illness experience: Implications for the ethics of patient involvement in health professions education

In response to calls to increase patient involvement in health professions education (HPE), educators are inviting patients to play a range of roles in the teaching of clinical trainees. However, there are concerns that patients involved in educational programs are seen as representing a demographic larger than themselves: their disease, their social group or even patients as a whole. This leads to difficult ethical challenges related to representation, including problems of tokenistic inclusion and of inadvertently essentializing marginalized groups. We propose that conceptualizing patients as experts in their illness experience can help resolve these dilemmas of representation equitably and effectively. Just as clinical experts are involved in HPE to share their expertise and represent their clinical experience, so too should patients be invited to participate in HPE explicitly for their expertise in their illness experience. This framing clarifies the goals of patient involvement as technocratic rather than tokenistic, mandates meaningful contributions by patients, and helps frame patient involvement for learners as the presentation of expert perspectives.

Contributors are representative, as long as they agree: How confirmation logic overrides effort to achieve synthesis in applied health research

Introduction

The paradox of representation in public involvement in research is well recognized, whereby public contributors are seen as either too naïve to meaningfully contribute or too knowledgeable to represent ‘the average patient’. Given the underlying assumption that expertise undermines contributions made, more expert contributors who have significant experience in research can be a primary target of criticism. We conducted a secondary analysis of a case of expert involvement and a case of lived experience, to examine how representation was discussed in each.

Methods

We analysed a case of a Lived Experience Advisory Panel (LEAP) chosen for direct personal experience of a topic and a case of an expert Patient and Public Involvement (PPI) panel. Secondary analysis was of multiple qualitative data sources, including interviews with the LEAP contributors and researchers, Panel evaluation data and documentary analysis of researcher reports of Panel impacts. Analysis was undertaken collaboratively by the author team of contributors and researchers.

Results

Data both from interviews with researchers and reported observations by the Panel indicated that representation was a concern for researchers in both cases. Consistent with previous research, this challenge was deployed in response to contributors requesting changes to researcher plans. However, we also observed that when contributor input could be used to support research activity, it was described unequivocally as representative of ‘the patient view’. We describe this as researchers holding a confirmation logic. By contrast, contributor accounts enacted a synthesis logic, which emphasized multiplicity of viewpoints and active dialogue. These logics are incompatible in practice, with the confirmation logic constraining the potential for the synthesis logic to be achieved.

Conclusion

Researchers tend to enact a confirmation logic that seeks a monophonic patient voice to legitimize decisions. Contributors are therefore limited in their ability to realize a synthesis logic that would actively blend different types of knowledge. These different logics hold different implications regarding representation, with the synthesis logic emphasizing diversity and negotiation, as opposed to the current system in which ‘being representative' is a quality attributed to contributors by researchers.

Patient or Public Contribution

Patient contributors are study coauthors, partners in analysis and reporting.

Patients' perspectives on medical students' professionalism: Blind spots and opportunities

BACKGROUND

Research has acknowledged the value of patients as essential stakeholders in medical education, yet educators have not adequately incorporated patients' perspectives into medical students' developing professionalism. Our purpose was to explore patients' perceptions of professional behaviour in medical students as a first step to considering patients' potential roles in assessing professionalism.

METHODS

Building on the existing framework of the 'disavowed curriculum', we used a constructivist grounded theory approach to interview and analyse data from 19 patients (11 W, 8 M) at one urban hospital. Each participant watched five video scenarios that depict professionally challenging situations commonly faced by medical students, after which they were asked to put themselves in the position of both the patient and the student depicted in each scenario, and to discuss what they felt would be appropriate or inappropriate behaviours from each perspective.

RESULTS

Patients' responses replicated all elements of the disavowed curriculum, including principles of professionalism, the student's affect or internal factors, and potential implications of actions. Their responses reflected avowed, unavowed and disavowed rationales. Participants also identified novel principles, including hide dissension in the ranks, respect privacy, advocate for yourself and have trust in the system. Patients conveyed an understanding of the multiple competing factors students must balance (e.g., providing optimal care while maximising educational opportunities) and appeared to empathise with some of the pressures students face.

CONCLUSIONS

Our findings point to significant blind spots in previous research based on faculty and student perspectives of professionalism. Knowing what patients perceive as important will allow educational and assessment efforts to be refined to reflect their values. Our work begins the process of understanding how best to include patients in the assessment of medical learners.

Teaching with madness/'mental illness' autobiographies in postsecondary education: ethical and epistemological implications

This paper presents a critical interpretive synthesis of 53 articles describing the pedagogical use of madness/'mental illness' autobiographical narratives in postsecondary education. Focusing on instructor intentions and representations of student learning outcomes, findings indicate that narratives are most commonly used as 'learning material' to engage students in active learning, cultivate students' empathy, complement dominant academic/professional knowledges, illustrate abstract concepts and provide 'real'-life connections to course content. This paper contributes to a conversation across the intellectual traditions of Mad studies, medical humanities, educational research, stigma reduction and service user involvement to interrogate pedagogical uses of autobiographical narratives that remain in uncritical educational terms rather than as a matter of justice for Mad communities. While teaching with narratives will not inevitably result in social justice outcomes, thoughtful engagement with the ethical and epistemological considerations raised throughout this review may increase this possibility by shifting when, why and how we teach with autobiography.

Towards a feminist philosophy of engagements in health-related research

Engagement with publics, patients, and stakeholders is an important part of the health research environment today,and different modalities of 'engaged' health research have proliferated in recent years. Yet, th ere is no consensus on what, exactly, 'engaging' means, what it should look like, and what the aims, justifications, or motivations for it should be. In this paper, we set out what we see as important, outstanding challenges around the practice and theory of engaging and consider the tensions and possibilities that the diverse landscape of engaging evokes. We examine the roots, present modalities and institutional frameworks that have been erected around engaging, including how they shape and delimit how engagements are framed, enacted, and justified. We inspect the related issue of knowledge production within and through engagements, addressing whether engagements can, or should, be framed as knowledge producing activities. We then unpack the question of how engagements are or could be valued and evaluated, emphasising the plural ways in which 'value' can be conceptualised and generated. We conclude by calling for a philosophy of engagements that can capture the diversity of related practices, concepts and justifications around engagements, and account for the plurality of knowledges and value that engagements engender, while remaining flexible and attentive to the structural conditions under which engagements occur. Such philosophy should be a feminist one, informed by feminist epistemological and methodological approaches to equitable modes of research participation, knowledge production, and valuing. Especially, translating feminist tools of reflexivity and positionalityinto the sphere of engagements can enable a synergy of empirical, epistemic and normative considerations in developing accounts of engaging in both theory and praxis. Modestly, here, we hope to carve out the starting points for this work.

Reconceptualizing the Family to Improve Inclusion in Childhood Disability Research and Practice

The World Health Organization's International Classification of Functioning, Disability and Health recognizes that environmental factors impact well-being and life participation for children with disabilities. A primary environment in which children grow and learn is the family. The importance of family has long been recognized in family-centered practice and family-centered research. Although family-centered services and research have been critically explored, the concept of family has received less critical attention in rehabilitation literature. The family construct is due for an updated conceptualization with careful consideration of the implications for childhood disability rehabilitation practice and research. Interrogating the family construct asks questions such as: who is included as a part of the family? Which family structures are prioritized and valued? What is the potential harm when some families are ignored or underrepresented in childhood disability practice and research? What implications could a modern rethinking of the concept of family have on the future of childhood rehabilitation practice and research? This perspective article raises these critical questions from the authors' perspectives as parents of children with disabilities, child focused rehabilitation professionals, and researchers that focus on service delivery in children's rehabilitation and family engagement in research. A critical reflection is presented, focused on how the construct of family affects children's rehabilitation practice and research, integrating concepts of equity, inclusion and human rights. Practical suggestions for children's rehabilitation service providers and researchers are provided to aid in inclusive practices, critical reflection, and advocacy.

Metaphors of organizations in patient involvement programs: connections and contradictions

PURPOSE

In this paper, we contribute to the theorizing of patient involvement in organizational improvement by exploring concepts of "learning from patients" as mechanisms of organizational change. Using the concept of metaphor as a theoretical bridge, we analyse interview data (n = 20) from participants in patient engagement activities from two case study organizations in Ontario, Canada. Inspired by classic organizational scholars, we ask "what is the organization that it might learn from patients?"

DESIGN/METHODOLOGY/APPROACH

Patient involvement activities are used as part of quality improvement efforts in healthcare organizations worldwide. One fundamental assumption underpinning this activity is the notion that organizations must "learn from patients" in order to enact positive organizational change. Despite this emphasis on learning, there is a paucity of research that theorizes learning or connects concepts of learning to organizational change within the domain of patient involvement.

FINDINGS

Through our analysis, we interpret a range of metaphors of the organization, including organizations as (1) power and politics, (2) systems and (3) narratives. Through these metaphors, we display a range of possibilities for interpreting how organizations might learn from patients and associated implications for organizational change.

ORIGINALITY/VALUE

This analysis has implications for how the framing of the organization matters for concepts of learning in patient engagement activities and how misalignments might stymie engagement efforts. We argue that the concept and commitment to "learning from patients" would be enriched by further engagement with the sociology of knowledge and critical concepts from theories of organizational learning.

Towards a feminist philosophy of engagements in health-related research

Engagement with publics, patients, and stakeholders is an important part of the health research environment in the UK and beyond today, and different 'engaged' health research modalities have proliferated in recent years. Yet, the conceptual landscape currently surrounding engagement is contested. There is no consensus on what, exactly, 'engaging' means, what it should look like, and what the aims, justifications, or motivations for it should be. In this paper, we set out what we see as important, outstanding challenges around the practice and theory of engaging and consider the tensions and possibilities that the diverse landscape of engaging evokes. We examine the roots, present modalities and institutional frameworks that have been erected around engaging, including how they shape and delimit how engagements are framed, enacted, and justified. We inspect the related issue of knowledge production within and through engagements, addressing whether engagements can, or should, be framed as knowledge producing activities. We then unpack the question of how engagements are or could be valued and evaluated, emphasising the plural ways in which 'value' can be conceptualised and generated. We conclude by calling for a philosophy of engagements that can capture the diversity of related practices, concepts and justifications around engagements, and account for the plurality of knowledges and kinds of value that engagements engender, while remaining flexible and attentive to the structural conditions under which engagements occur. Such philosophy should be a feminist one, informed by feminist epistemological and methodological approaches to equitable modes of research participation, knowledge production, and valuing. This will enable a synergy of empirical, epistemic, and normative considerations in developing accounts of engaging in both theory and praxis. Modestly, here, we hope to carve out the starting points for this work.

Patient involvement in medical education: To what problem is engagement the solution?

CONTEXT

Patient and public engagement is gaining momentum across many domains of health care, inclusive of education and research. In this framing, engagement is offered as a solution to a myriad of problems. Yet, the way problems and solutions are linked together may be assumed, rather than made explicit. In the absence of clarity, there is a risk that solutions that may have worked in one domain of health care could falter, or even create new problems, in another.

METHODS

We use a model from organisational studies as a way to make sense of the relationships between the problems, solutions and stakeholders operating in the name of patient and public engagement in health care. The 'garbage can model' is a playfully phrased but meaningful attempt to decipher the complex world of decision making in organisations. We use this model to guide our framing of the solutions of patient engagement practice and the wide range of problem statements that animate all of this activity.

RESULTS

Following a discussion of the complexity of the field of patient engagement, we identify strategies for educators to conceptually weave problem statements, solutions and stakeholders together in mosaics of engagement activity. We further suggest a movement away from considering problems to be solved to thinking about polarities to be navigated.

CONCLUSIONS

As patient engagement becomes more embedded in decision-making spaces in health professions education, we need a better understanding of how decisions are actually made in these organisations. We also need to consider that our most treasured solutions may have an uneasy fit, and some unintended consequences, as they enter new domains of health care. Finally, we advocate for critical approaches not just to the solutions of patient engagement, but to understand problem statements as they are defined, upheld and disrupted through all of this work.

Patients as teachers and arts-based reflection in surgical clerkship: A preliminary exploration

BACKGROUND

Involving patients in medical education as teachers is not a novel approach, yet it has not been widely adopted by undergraduate surgical curricula in Canada. The Patients as Teachers initiative in surgery (PAT) program, with an arts-based reflection assignment, was developed for surgical clerks with the goals of emphasizing patient-centredness in surgical practice, humanistic aspects of medicine, and to counterbalance the commonplace emphasis on technical competency in surgery.

METHODS

Qualitative data was collected exploring the question: What was the experience and impact of the PAT program on patient teachers and students? Patient teachers (n = 5) were invited to participate in one-on-one interviews and students (n = 46) were invited to participate in focus groups at the end of the program.

RESULTS

Findings converged around two main themes: what students/patient teachers valued about the PAT program and what they perceived was learned. While patient teachers felt a sense of emotional healing and appreciated a chance to contribute to medical education, students valued having protected time to learn in depth from the patient teachers. Students also begrudgingly came to appreciate the arts-based reflection assignment.

CONCLUSION

By bringing patient voice to the forefront and encouraging reflection, the PAT program emphasized to students the compassionate and humanistic side of surgical care. Future studies could examine the mechanisms by which learning occurs and long-term impacts.

Challenges of Patient Engagement in an HIV Clinical Research Program: A Qualitative Analysis of Stakeholder Accounts

Patient engagement (PE) promotes collaboration between stakeholders (researchers, patients, clinicians, etc). It often faces challenges due to tensions between its ethical/political and scientific underpinnings. This article explores how stakeholders applied the guiding principles of a PE project (“co-build,” “support and mutual respect,” and “inclusiveness”) for an HIV clinical research program initiated in January 2016. Three researchers/clinicians, a PE agent, and 2 patients held 3 meetings (June-October 2018) to discuss challenges faced and how these impacted their approach to PE. Regular stakeholder discussions about PE in clinical research could be documented and help guide PE to better meet stakeholder needs.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.

Perceptions of people with respiratory problems on physician performance evaluation-A qualitative study

BACKGROUND

Despite increasing calls for patient and public involvement in health-care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention.

OBJECTIVE

The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence.

DESIGN

A qualitative study based on semi-structured interviews.

SETTING AND PARTICIPANTS

The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling.

METHODS

Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment.

RESULTS

The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor-patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance.

DISCUSSION AND CONCLUSION

Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback.

Using qualitative Health Research methods to improve patient and public involvement and engagement in research

PLAIN ENGLISH SUMMARY

Patient engagement (or patient and public involvement) in health research is becoming a requirement for many health research funders, yet many researchers have little or no experience in engaging patients as partners as opposed to research subjects. Additionally, many patients have no experience providing input on the research design or acting as a decision-making partner on a research team. Several potential risks exist when patient engagement is done poorly, despite best intentions. Some of these risks are that: (1) patients' involvement is merely tokenism (patients are involved but their suggestions have little influence on how research is conducted); (2) engaged patients do not represent the diversity of people affected by the research; and, (3) research outcomes lack relevance to patients' lives and experiences.Qualitative health research (the collection and systematic analysis of non-quantitative data about peoples' experiences of health or illness and the healthcare system) offers several approaches that can help to mitigate these risks. Several qualitative health research methods, when done well, can help research teams to: (1) accurately incorporate patients' perspectives and experiences into the design and conduct of research; (2) engage diverse patient perspectives; and, (3) treat patients as equal and ongoing partners on the research team.This commentary presents several established qualitative health research methods that are relevant to patient engagement in research. The hope is that this paper will inspire readers to seek more information about qualitative health research, and consider how its established methods may help improve the quality and ethical conduct of patient engagement for health research.

ABSTRACT

Background Research funders in several countries have posited a new vision for research that involves patients and the public as co-applicants for the funding, and as collaborative partners in decision-making at various stages and/or throughout the research process. Patient engagement (or patient and public involvement) in health research is presented as a more democratic approach that leads to research that is relevant to the lives of the people affected by its outcomes. What is missing from the recent proliferation of resources and publications detailing the practical aspects of patient engagement is a recognition of how existing research methods can inform patient engagement initiatives. Qualitative health research, for example, has established methods of collecting and analyzing non-quantitative data about individuals' and communities' lived experiences with health, illness and/or the healthcare system. Included in the paradigm of qualitative health research is participatory health research, which offers approaches to partnering with individuals and communities to design and conduct research that addresses their needs and priorities. Discussion The purpose of this commentary is to explore how qualitative health research methods can inform and support meaningful engagement with patients as partners. Specifically, this paper addresses issues of: rigour (how can patient engagement in research be done well?); representation (are the right patients being engaged?); and, reflexivity (is engagement being done in ways that are meaningful, ethical and equitable?). Various qualitative research methods are presented to increase the rigour found within patient engagement. Approaches to engage more diverse patient perspectives are presented to improve representation beyond the common practice of engaging only one or two patients. Reflexivity, or the practice of identifying and articulating how research processes and outcomes are constructed by the respective personal and professional experiences of researchers and patients, is presented to support the development of authentic, sustainable, equitable and meaningful engagement of patients as partners in health research. Conclusions Researchers will need to engage patients as stakeholders in order to satisfy the overlapping mandate in health policy, care and research for engaging patients as partners in decision-making. This paper presents several suggestions to ground patient engagement approaches in established research designs and methods.

Alignments and differentiations: People with illness experiences seeking legitimate positions as health service developers and producers

Health policies and strategies promote the involvement of people with illness experiences in service development and production, integrating them into settings that have traditionally been domains of health professionals. In this study, we focus on the perspectives of people with personal illness experiences and explore how they justify involvement, position themselves as legitimate actors and forge collaborative relationships with health professionals. We have used discourse analysis in analysing individual interviews conducted with peer support workers and experts by experience (n = 17) who currently work in Finnish health services. The interviewees utilised discourses of empowerment, efficiency and patient-centeredness, aligning themselves with the justifications constructed by patient movements additionally to those found in current health policies. Both groups wanted to retain critical distance from professionals in order to voice criticisms of current care practices, yet they also frequently aligned themselves with professionals in order to gain legitimacy for their involvement. They adopted professional traits that moved them further from being lay participants sharing personal experiences and adopted an expert position. Although national-level policies provided backing and legitimacy for involvement, the lack of local-level guidance could hinder the practical implementation and make involvement largely dependent of professionals' discretion.

Dilemmas of Representation: Patient Engagement in Health Professions Education

The role of the patient in bedside teaching has long been a matter of consideration in health professions education. Recent iterations of patient engagement include patients as storytellers, members of curriculum planning committees, guest lecturers, and health mentors. While these forms of patient engagement are reported to have many benefits for learners, educators, and the patients themselves, there is concern that such programs may not be representative of the diversity of patients that health care professionals will encounter throughout their careers. This problem of representation has vexed not only educators but also sociologists and political scientists studying patients' and the public's involvement in arenas such as health services research, policy, and organizational design.In this Perspective, the authors build on these sociological and political science approaches to expand our understanding of the problem of representation in patient engage-ment. In doing so, the authors' reconfiguration of the problem sheds new light on the dilemma of representation. They argue for an understanding of representation that not only is inclusive of who is being represented but that also takes seriously what is being represented, how, and why. This argument has implications for educators, learners, administrators, and patient participants.

Beyond catharsis: the nuanced emotion of patient storytellers in an educational role

CONTEXT

As health care organisations seek to cultivate patient and family-centred care, patient storytelling has emerged as a valued educational resource. However, repeatedly harnessing patient perspectives to educate health care professionals may have consequences. We need robust insight into what it means to be a patient storyteller in order to ensure ethical and appropriate engagement with patients as an educational resource.

METHODS

Constructivist grounded theory was used to explore the experience of patients involved in a storytelling curriculum as part of hospital staff continuing education. All 33 storytellers were invited by e-mail to participate in the study. Twenty-six storytellers responded to the invitation, and 25 could be scheduled to participate. Using theoretical sampling, semi-structured interviews were conducted and analysed in a process that was inductive, iterative and comparative.

RESULTS

Participants described the central role of emotions in their storytelling experience, which varied from 1 to 25 tellings over a period of 1 month to 2 years. These emotions were shaped by the passage of time, repetition of storytelling and audience acknowledgement. However, emotion remained unpredictable and had lingering implications for storytellers' vulnerability.

CONCLUSION

The multiple storytelling experiences of our participants and ongoing educational nature of their role provides unique insight into how emotions ebb and flow across tellings, how emotions can be both a surprise and a rhetorical strategy, and how emotions are influenced by audience acknowledgement. These findings contribute to an emerging conversation regarding the power and politics of selecting and using storytellers for organisational purpose. Implications include how we support patient storytellers in educational roles and how we can sustainably integrate patient storytelling into health professional education.

'Can the patient speak?': postcolonialism and patient involvement in undergraduate and postgraduate medical education

CONTEXT

Patients are increasingly being engaged in providing feedback and consultation to health care institutions, and in the training of health care professionals. Such involvement has the potential to disrupt traditional doctor-patient power dynamics in significant ways that have not been theorised in the medical literature. Critical theories can help us understand how power flows when patients are engaged in the training of medical students.

METHODS

This paper applies postcolonial theory to the involvement of patients in the development and delivery of medical education. First, I review and summarise the literature around patient involvement in medical education. Subsequently, I highlight how postcolonial frameworks have been applied to medical education more broadly, extrapolating from the literature to apply a postcolonial lens to the area of patient engagement in medical education.

CONCLUSION

Concepts from postcolonial theory can help medical educators think differently about how patients can be engaged in the medical education project in ways that are meaningful and non-tokenistic. Specifically, the positioning of the patient as 'subaltern' can provide channels of resistance against traditional power asymmetries. This has curricular and methodological implications for medical education research in the area of patient engagement.

Three Sides to Every Story: Preparing Patient and Family Storytellers, Facilitators, and Audiences

BACKGROUND

There is a growing recognition that patient engagement is necessary for the cultivation of patient- and family-centered care (PFCC) in the hospital setting. Acting on the emerging understanding that hearing stories from our patients gives valuable insight about our ability to provide compassionate PFCC, we developed an educational patient experience curriculum at our acute care teaching hospital.

OBJECTIVES

To understand the benefits and consequences of patient storytelling and to explore the impact of our curriculum on participants.

METHODS

The curriculum was codesigned with patients to illustrate the value and meaning of PFCC to health professional audiences. We surveyed audience members at nursing orientation events and interviewed the patient storytellers who shared their stories.

RESULTS

Participants indicated that patient stories could serve as lessons or reminders about the dimensions of PFCC and could inspire changes to practice. Storytellers reported an immensely rewarding experience and highlighted the value of educating and connecting with participants. However, they reported that the experience could also pose emotional challenges.

CONCLUSION

Careful and considerate facilitation of storytelling sessions is crucial to the delivery of a curriculum that is beneficial to both patients and participants. Our storytelling framework offers a novel approach to engaging patients in education, and it contributes to our existing understanding of how patient engagement efforts resonate within organizations.

Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique

Background The development of new virtual care technologies (including telehealth and telemedicine) is growing rapidly, leading to a number of challenges related to health policy and planning for health systems around the world. Methods We brought together a diverse group of health system stakeholders, including patient representatives, to engage in policy dialogue to set health system priorities for the application of virtual care in the primary care sector in the Province of Ontario, Canada. We applied a nominal group technique (NGT) process to determine key priorities, and synthesized these priorities with group discussion to develop recommendations for virtual care policy. Methods included a structured priority ranking process, open-ended note-taking, and thematic analysis to identify priorities. Results Recommendations were summarized under the following themes: (a) identify clear health system leadership to embed virtual care strategies into all aspects of primary and community care; (b) make patients the focal point of health system decision-making; (c) leverage incentives to achieve meaningful health system improvements; and (d) building virtual care into streamlined workflows. Two key implications of our policy dialogue are especially relevant for an international audience. First, shifting the dialogue away from technology toward more meaningful patient engagement will enable policy planning for applications of technology that better meet patients' needs. Second, a strong conceptual framework on guiding the meaningful use of technology in health care settings is essential for intelligent planning of virtual care policy. Conclusions Policy planning for virtual care needs to shift toward a stronger focus on patient engagement to understand patients' needs.

Patient advocate perspectives on involvement in HTA: an international snapshot

PLAIN ENGLISH SUMMARY

A number of health technology assessment (HTA) organisations have developed processes to engage patients in the assessment of new health technologies such as pharmaceuticals, diagnostic tests, devices or medical procedures. Typically, this involves the HTA agency providing an opportunity for patient advocates and their patient organisations (support groups for patients with a specific disease or condition) to provide submissions detailing experiences with the disease and the health technology that is being assessed. While some literature exists about how HTA agencies view the engagement of patients in the HTA process, it is not yet clear how the patient advocates and patient organisations themselves view this engagement. To answer this question, we surveyed the views of patient advocates who were members of patient organisations known to be engaged in the process of HTA or evidence-based practice. Snowballing - that is, passing on the survey invitation from individuals invited to take part in the survey to other individuals - occurred in one of the countries. The responses in this country provided a very useful comparison between the views of people who were appointed as the 'patient representatives' on an HTA committee with those who contributed input as part of the general patient organisation engagement process. Our findings identify gaps in understanding of the purpose of patient involvement and whether patient organisations felt their input made a difference, the information and support provided, and if and how feedback is given to the patient organisations. Our work can help inform further research as well as continuing improvements in HTA patient engagement processes.

ABSTRACT

Background Patient involvement in health technology assessment (HTA) processes is becoming more frequent. However, it is not clear how patient advocates and their disease-based patient organisations that are involved in HTA view their involvement. We report on the results of an international survey of patient advocates and members of patient organisations about their experiences and perceptions of that involvement. Methods A 16-question survey was sent out to patient advocates and members of patient groups known to be involved in HTA processes or evidence-based practice. The survey consisted of open-ended questions focusing on respondent characteristics, stage and nature of involvement, support from HTA agencies for involvement, purpose of involvement, feedback on involvement, and whether the respondents felt that their input made a difference. Results Of 16 individuals who received the survey, 15 responded. Three, from Italy, Israel and Japan, were not involved in HTA in their country. Respondents from the following countries reported involvement in HTA processes: Canada, England, Scotland, and Wales, The Netherlands, Australia, Taiwan. The respondents indicated that HTA agencies reach out to them either actively or passively, and that their involvement is often at the appraisal stage of HTA. Typically, they reported involvement as either participants in committees or providers of submissions to HTA agencies. A wide range of approaches to supporting patient involvement by the HTA agencies was identified by respondents - including personal and telephone support, online resources, training and provision of information - but the level and type of support reported was uneven across jurisdictions. Not all respondents were clear on the purpose of their involvement in HTA, although some were able to cite specific examples of how their input made a difference; members of an HTA decision-making committee appeared to have a better understanding and were able to give examples. Feedback from HTA agencies to the patient groups on their submissions is often not provided. Conclusions Although considerable progress has been made in terms of engaging patients and patient groups in HTA, gaps remain in how involvement is supported, including facilitating involvement, clarity on roles, two-way flow of information, and methods for enhancing communication between patient organisations and HTA agencies.